Most nurse practitioners, physician assistants, and physician prescribers of chronic pain opiate drugs do not have any formal training in the diagnosis, treatment, or safe medication management and monitoring for patients on high dosage narcotic preparations. Many chronic pain specialists often do not even own a comprehensive textbook on chronic pain medicine. Their practices are often quite limited in scope and consist simply of prescribing patients the opioid drugs they request. These chronic pain specialists often have minimal knowledge of relevant anatomy, physiology, pharmacology, mental health, substance abuse, and drug-diversion-related issues. Verifiable functional improvement in their patients is limited and many of their patients have no true improvements in their medical, occupational, or social lives with treatments that often consist solely of high-dosage narcotic regimens. Further complicating matters is the fact that a disproportionately high number of patients in these practices are involved in substance abuse and/or commercial drug diversion activities, along with having high rates of accidental overdose death and criminal commercial drug diversion activities.
On the other hand, there are a growing number of highly trained interventional chronic pain specialists with fellowship training in performing invasive chronic pain procedures. Unfortunately, a very large percentage of invasive chronic non-cancerous pain treatment procedures have never been scientifically proven to be any more effective than placebos. Complicating matters is the fact that many of these procedures are not inexpensive. These well-trained interventionists often recommend expensive unproven procedures as the mainstay of chronic non-cancerous chronic pain treatment and then delegate narcotic and other controlled substance prescribing to employed and/or contracted midlevel providers that may have their own DEA licenses, but who have no formal training or certification in chronic pain management or addiction medicine/mental health.
Safety measures for prescription opioids and other controlled substances that would help address epidemic-level drug-related problems, including death from accidental overdose, brain damage, drug DUI and motor vehicle accidents, and massive criminal controlled substance drug diversion activities in the that supply the major gateway drugs leading to drug addiction, are becoming an area of research and development interest. Drug overdose has become the number one cause of accidental death in the USA. Our country is currently experiencing an ever-growing epidemic of accidental deaths due to Rx drug overdose, and most of these deaths involve narcotic (opioid) pain pills. The CDC has declared this Rx poisoning epidemic to be a national healthcare emergency and it involves persons who ingest narcotic pain pills for the purposes of pain control and/or recreational use. Tragically, many accidental narcotic overdose victims do not die, but rather suffer severe permanent brain damage as a result of the respiratory depression produced by toxic doses of narcotics. The excess costs to the healthcare system and society caused by minimally controlled Rx drug abuse and drug diversion are in the hundreds of billions of dollars per year. One of the major contributing factors to this problem is that most opioid prescribing nurses, physicians, and PAs normally write prescriptions for 30-day (or longer) supplies of pain medicines to patients who are at elevated risk for accidental overdose, drug abuse, and/or commercial drug diversion. Too many patients receive large monthly supplies of powerful narcotic drugs and then either take toxic doses of these pills or sell these pills to criminal commercial drug dealers for a large profit. As a result, wrongful death lawsuits against prescribing nurses, physician assistants, and physicians are on the rise. More importantly, the current situation has caused tragedy for hundreds of thousands of U.S. families.
One example of commercial drug diversion is a patient who pretends to have a painful condition and gets a careless medical provider to prescribe oxycontin 80 mg tablets three times per day. This equals 240 mg of oxycodone per day or 7,200 mg per month. The average price for illicit oxycodone in many locales is $1/mg, which means that the commercial drug diverter can easily make over $4,000 per month tax free on each Rx. Many diverters see half a dozen careless providers each month and are able to net over $20,000 per month tax free. Drug diversion is especially prevalent in the Medicare and Medicaid patient populations, which means that taxpayers are directly subsidizing criminal diversion rings and heroin producers and heroin dealers. To date, law enforcement has been unable to curtail the rapidly growing business of commercial drug diversion in the USA. In short, criminal commercial diversion is so widespread because it is such an easy way to make huge amounts of tax-free dollars. Law enforcement cannot even begin to control the problem. Medical and mid-level regulatory boards are also unable to effectively deal with this problem because their investigative budgets have been greatly reduced and many simply do not have enough qualified investigators. Meanwhile, intensive lobbying efforts by the pharmaceutical industry and the “grassroots” pain patient advocacy that they heavily fund have had a chilling effect on the development of effective mandatory counter diversion measures in the U.S. Some conscientious narcotic drug prescribers try to utilize controlled substance Rx's with smaller numbers of pills for their high-risk patients in order to increase patient and societal safety; however, this requires patients to go to both the doctor's office and the pharmacy every few days and this causes difficulties for patients insofar as transportation and co-payments to doctors and pharmacists.
Methadone clinics also have serious problems with patient drug abuse, overdose and commercial diversion, in that they normally allow compliant patients to stop coming to the clinic every morning to get their daily dose of this narcotic maintenance drug. These reliable patients are then given week-long or even multiple week supplies of bulk liquid methadone that is often implicated in accidental drug overdoses and/or criminal commercial drug diversion. Many methadone clinics have grossly inadequate anti-diversion policies and procedures. Finally, children depend upon criminals that commercially divert narcotic pain drugs to fuel their own drug abuse, addiction, and overdose tragedies. This is because 15-year-olds cannot obtain powerful narcotic prescriptions from physicians or nurses without the written consent of their parents, and most parents will not consent to their 14-year-olds being placed on long-term high-dose narcotic drug regimens for relatively minor conditions, as is the case for many adults. A 14-year-old might be able to sneak a bit of opioid drugs from his or her parent's medicine chest, but to become addicted to opiates, humans normally must ingest high doses of narcotic drugs for a couple of months. There simply are not enough powerful narcotic drugs to become addicted to in the typical family's medicine chest. However, young people do sometimes accidently overdose and die by ingesting unsecured narcotics and other controlled substances from the family medicine cabinet.
Studies of young heroin addicts in the USA reveal that the majority of them first became addicted to Rx pain pills and then were switched to cheaper heroin by their drug dealers when they could no longer afford to buy the more expensive diverted pain pills. Today, thanks to uncontrolled diversion of opioid/narcotic drugs, we have the largest heroin addiction epidemic among young people in our country's history. Most of the growth in criminal-drug-diversion-related youth heroin addiction appears to be in the Caucasian population.